Statutory Accident Benefits Schedule matters (SABS) - OFSCDRS

The applicants were injured in two motor vehicle accidents in 1995.

The insurer argued that an excluded driver endorsement signed by the applicants barred the husband from receiving further statutory accident benefits, as he was driving the wife's vehicle at the time of both accidents.

The arbitrator found that the endorsement was valid and understood by the husband, but the insurer could only rely on it for the second accident because it had not received the signed endorsement prior to the first accident.

The endorsement barred the husband's claim for income replacement benefits for the second accident, but had no effect on the wife's claims for benefits.

The applicant was injured in a motor vehicle accident and claimed ongoing caregiver benefits, housekeeping expenses, psychological counselling, and a special award after the insurer terminated her benefits.

The arbitrator found that the applicant suffered a substantial inability to perform caregiver tasks due to physical and psychological impairments until her condition stabilized in January 1999, awarding caregiver benefits for that period.

The arbitrator also awarded a nominal amount for housekeeping expenses and an $8,000 special award, finding the insurer unreasonably terminated psychological counselling and vocational retraining benefits without a reasonable basis.

The appellant was injured in a motor vehicle accident and received weekly income benefits for over 156 weeks.

The insurer terminated benefits, and an arbitrator upheld the termination, finding the appellant did not meet the post-156 week test of being continuously prevented from engaging in suitable employment.

On appeal, the appellant argued the arbitrator erred in law by focusing on whether she suffered a head injury, relying on hearsay evidence, and failing to properly analyze suitable employment options.

The Director's Delegate dismissed the appeal, finding the causation issue was properly before the arbitrator, the reliance on hearsay was permissible, and the arbitrator's conclusions were supported by the evidence.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated them, relying on reports from its medical examiners.

The applicant sought arbitration for ongoing income replacement benefits, medical expenses, housekeeping services, and a special award.

The arbitrator found that the applicant suffered from severe depression and post-traumatic stress disorder caused by the accident, rendering her substantially unable to perform her employment tasks.

The arbitrator rejected the insurer's psychiatric expert as a partisan advocate and found the insurer acted unreasonably in terminating benefits despite overwhelming evidence of the applicant's psychological disability.

The applicant was awarded all claimed benefits and a $10,000 special award.

The Applicant was injured in a motor vehicle accident and applied for statutory accident benefits.

A dispute arose regarding the calculation of her gross income for income replacement benefits.

The Applicant was both employed and self-employed in the four weeks preceding the accident.

The arbitrator held that under section 8(2) of the Statutory Accident Benefits Schedule, because the Applicant was self-employed at any time during the four weeks before the accident, she must designate either the 52 weeks before the accident or the last fiscal year of her business to calculate her gross income.

The Applicant was awarded her reasonable expenses of the arbitration.

The applicant was injured in a motor vehicle accident and sought income replacement benefits, which the insurer terminated for insufficient documentation of pre-accident income.

At the arbitration hearing, the insurer brought a preliminary motion to dismiss the application, arguing the applicant failed to comply with a pre-hearing order to produce his complete WCB file, clinical notes, and banking records.

The arbitrator dismissed the motion, finding the applicant had not refused to comply but had provided the documents he intended to rely on, and declined to draw an adverse inference at the preliminary stage.

However, because the applicant's late production of voluminous records caused substantial delay, the arbitrator ordered the applicant to pay the insurer's expenses for the preliminary hearing.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits.

A dispute arose regarding the calculation of her income replacement benefits.

The arbitrator held that draws taken from the family business, which were declared as dividends for tax purposes, formed part of the applicant's regular remuneration and should be included in her gross annual income.

The arbitrator also held that unemployment insurance premiums should not be deducted from her gross annual income because she was exempt from paying them as a joint owner of the business.

The applicant was injured in a pedestrian motor vehicle accident and received statutory accident benefits until the insurer terminated weekly income benefits.

The applicant applied for arbitration but failed to attend the hearing or maintain contact with her legal representatives, who were permitted to withdraw.

Proceeding in her absence, the arbitrator accepted the insurer's uncontested medical evidence that the applicant did not suffer from a physical or psychological impairment preventing her from working.

The claim for benefits was dismissed, and the applicant was ordered to pay the insurer's legal expenses of $1,636.95, though the arbitrator declined to order the applicant to pay the insurer's filing fee as the initial claim was not frivolous or vexatious.

The applicant sought accident benefits following a motor vehicle accident but failed to attend the arbitration hearing.

At the outset of the hearing, the arbitrator granted a motion by the applicant's counsel to be removed from the record due to a lack of instructions.

Proceeding in the applicant's absence, the arbitrator dismissed the claim for benefits as no evidence was presented.

The arbitrator further found that the applicant's conduct—including failing to provide medical information, ignoring communications, and failing to attend—amounted to an abuse of process under section 282(11.2) of the Insurance Act, and ordered the applicant to pay the insurer's assessment fee and disbursements.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated weekly income benefits.

The applicant applied for arbitration, seeking ongoing weekly income benefits, transportation expenses, and a special award.

The arbitrator found that the applicant suffered from chronic pain and depression caused by the accident, which continuously prevented him from engaging in any suitable employment.

The arbitrator ordered the insurer to pay ongoing weekly income benefits and transportation expenses.

However, the arbitrator also ordered the applicant to repay an overpayment of income replacement benefits due to his receipt of collateral benefits, and denied the request for a special award.

The applicant applied for arbitration of a dispute over statutory accident benefits but subsequently disappeared and failed to attend pre-hearing discussions or the arbitration hearing.

The arbitrator found that the applicant had constructively withdrawn his application and that his failure to pursue the claims amounted to an abuse of process.

The application was deemed withdrawn, and the applicant was ordered to pay the insurer's assessment fee of $3,000 and its arbitration expenses of $716.90.

The applicants' 16-year-old son died in a motor vehicle accident.

The insurer paid the parents a joint death benefit of $10,000 under the 1996 Statutory Accident Benefits Schedule.

The parents applied for arbitration, arguing they were each entitled to a separate $10,000 benefit.

The arbitrator held that under subparagraph 25(2)5(i) of the 1996 SABS, the insurer is required to pay a benefit of $10,000 to each person in respect of whom the insured person was a dependant at the time of the accident.

The insurer was ordered to pay an additional $5,000 to each parent.

The applicant was injured in a motor vehicle accident and received caregiver benefits from the insurer until they were terminated.

The applicant applied for arbitration more than two years after receiving the notice of termination.

The arbitrator found that the notice of termination was clear and unequivocal, and there was no evidence that the insurer was estopped from relying on the limitation period.

The arbitrator held that she had no jurisdiction to extend the time limits or grant relief from forfeiture.

The application for arbitration was dismissed as statute-barred.

The applicant, who sustained a traumatic brain injury in a motor vehicle accident, sought interim statutory accident benefits to cover the cost of upgrading his and his wife's airline tickets to first class and for hotel accommodations during a trip to Italy to visit family.

The applicant argued these expenses were necessary for his rehabilitation and to avoid overstimulation.

The arbitrator dismissed the motion for interim benefits, finding that the applicant failed to demonstrate the requisite need, necessity, or urgency, as the trip was voluntary and the 'emergent situation' was created by the applicant's own actions.

The applicant was injured in a motor vehicle accident and received income replacement benefits until they were terminated by the insurer.

The applicant filed for arbitration after the limitation period had expired.

The applicant argued that the insurer was estopped from relying on the limitation period due to an agreement at mediation, and that the insurer waived its right to rely on the limitation period through its subsequent conduct.

The arbitrator found that the insurer's conduct did not amount to estoppel or waiver, and dismissed the application for arbitration.

The insurer requested that two separate arbitrations involving the same applicant but different motor vehicle accidents be combined into a single hearing.

The applicant, who was self-represented, objected to the consolidation.

The arbitrator determined that under section 9.1(4) of the Statutory Powers Procedure Act, proceedings cannot be combined without the consent of the parties unless another Act or regulation explicitly allows it.

The arbitrator found that the general rule-making authority under section 21 of the Insurance Act and Rule 30 of the Dispute Resolution Practice Code were insufficient to override the SPPA's consent requirement.

Consequently, the insurer's request to combine the arbitrations was denied.

The appellant appealed an arbitration order denying his claim for weekly income benefits following a motor vehicle accident.

The appellant, a self-employed businessman, claimed he was unable to work as a transmission mechanic due to right wrist and shoulder injuries.

The Director's Delegate upheld the arbitrator's decision, finding that the appellant failed to provide credible, independent financial records to establish his pre-accident self-employment income or business losses.

Furthermore, the appellant's credibility was undermined by his failure to disclose a prior wrist fracture and surveillance evidence showing him working after the accident.

The appeal was denied.

The applicant was injured in a motor vehicle accident and sought weekly caregiver benefits and housekeeping expenses after the insurer terminated them.

The arbitrator found that the applicant suffered a partial inability to carry on a normal life due to her substantial inability to engage in pre-accident household activities, including cooking, heavy laundry, and cleaning.

The arbitrator awarded the claimed caregiver benefits, housekeeping expenses, interest, and arbitration expenses, noting that the insurer's surveillance and medical evidence did not sufficiently contradict the applicant's credible testimony regarding her impairments.

The Director's Delegate issued a correction to an appeal decision dated September 20, 1999.

Three references to s.28(4) on pages 7 and 9 of the original decision were corrected to s.24(8).

The applicant was injured in a motor vehicle accident and claimed income replacement benefits.

The insurer argued that the applicant's request for arbitration was barred by the two-year limitation period under the Insurance Act and the Statutory Accident Benefits Schedule.

The arbitrator found that the insurer's initial assessment forms did not constitute a clear and unequivocal refusal to pay benefits, as they requested further information to calculate the benefits.

The limitation period did not begin to run until the insurer explicitly denied the claim later.

Therefore, the applicant was not precluded from proceeding to arbitration.

Expenses were awarded to both parties for different hearing dates due to counsel's failure to attend.